‫ﺍﻟﺮﺣﻤﻦ ﺍﻟﺮﺣﻴﻢ‬ ‫ﺑﺴﻢ‬

‫ﺍﻟﺠﺎﻣﻌــﺔ ﺍﻷﺭﺩﻧﻴــــﺔ‬
‫ﺃﻣﺎﻧﺔ ﺳﺮ ﺍﻟﻤﺠﺎﻟﺲ‬
‫ﻟﺠﻨﺔ ﺍﻟﺘﻌﻴﻴﻦ ﻭﺍﻟﺘﺮﻗﻴﺔ‬

‫ﺍﺳﺘﻤﺎﺭﺓ ﻁﻠﺐ ﺗﻌﻴﻴﻦ‬

‫ﺍﺳـﻢ ﺍﻟﻤﺘﻘﺪﻡ ﻟﻠﻮﻅﻴﻔﺔ ‪ .. :‬رائد فخري شحادة أبو لطيفة‬

‫ﺍﻟﻮﻅﻴﻔﺔ ﺍﻟﻤﺘﻘﺪﻡ ﺇﻟﻴﻬﺎ ‪ .. :‬أستاذ مساعد‬

‫ﺍﻟﻜــﻠﻴـﺔ ﻭ ﺍﻟﻘﺴـــــم ‪ -:‬العلوم التربوية ‪ /‬المناهج والتدريس‪....‬‬

‫ﺍﻟﺘــــﺨـﺼــــﺺ‪....: -.. ..............‬‬

‫ﺗﺎﺭﻳـــﺦ ﺍﻹﻋــــــــﻼﻥ ‪................................................................................... :‬‬

‫* ﻣﻼﺣﻈﺎﺕ ‪:‬‬
‫ﻻ ﻳﻨﻈﺮ ﺇﻻ ﻓﻲ ﺍﻟﻄﻠﺒﺎﺕ ﺍﻟﺘﻲ ﺗﺸﻤﻞ ﺟﻤﻴﻊ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﻭﺍﻟﻮﺛﺎﺋﻖ ﺍﻟﻤﻄﻠﻮﺑﺔ ﻭﺍﻟﻤﻄﺎﺑﻘﺔ‬
‫ﻟﺸﺮﻭﻁ ﺍﻹﻋﻼﻥ ‪.‬‬
‫ﻳﺮﻓﻖ ﺑﺎﻟﻄﻠﺐ ﻗﺎﺋﻤﺔ ﺗﻔﺼﻴﻠﻴﺔ ﺑﺎﻻﻧﺘﺎﺝ ﺍﻟﻌﻠﻤﻲ ﺍﻟﻤﻨﺸﻮﺭ ﺃﻭ ﺍﻟﻤﻘﺒﻮﻝ ﻟﻠﻨﺸﺮ ‪.‬‬

‫ﻣﻼﺣﻈﺎﺕ ﻟﺠﻨﺔ ﺍﻟﺘﻌﻴﻴﻦ ﻭﺍﻟﺘﺮﻗﻴﺔ ‪:‬‬ ‫*‬

‫ﻣﻄﺎﺑﻖ‬

‫ﻣﺨﺎﻟﻒ‬
‫ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﺸﺨﺼﻴﺔ‬
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 ‫ﺍﻻﺳﻢ ﺍﻟﻜﺎﻣﻞ ‪............................................................................ :‬‬
‫ﺍﺳﻢ ﺍﻻﻡ ﻗﺒﻞ ﺍﻟﺰﻭﺍﺝ ‪................................................................... :‬‬
‫ﺃﻧﺜﻰ‬ ‫ﺍﻟﺠﻨﺲ ‪ :‬ﺫﻛﺮ‬
‫ﺍﻟﺮﻗﻢ ﺍﻟﻮﻁﻨﻲ ‪........................................................................... :‬‬
‫ﻣﻜﺎﻥ ﺍﻟﻮﻻﺩﺓ ‪............................................................................ :‬‬
‫‪//‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ ‪:‬‬
 ‫ﺍﻟﺠﻨﺴﻴﺔ ‪................................................................................. :‬‬
‫ﺍﻟﺪﻳﺎﻧﺔ ‪.................................................................................... :‬‬
‫ﺭﻗﻢ ﺟﻮﺍﺯ ﺍﻟﺴﻔﺮ ‪...................... :‬ﻣﻜﺎﻥ ﻭﺗﺎﺭﻳﺦ ﺻﺪﻭﺭﻩ ‪.......................................... :‬‬
‫ﺭﻗﻢ ﺩﻓﺘﺮ ﺍﻟﻌﺎﺋﻠﺔ ‪ ....................... :‬ﻣﻜﺎﻥ ﻭﺗﺎﺭﻳﺦ ﺻﺪﻭﺭﻩ ‪........................................ :‬‬
‫ﺍﻟﺤﺎﻟﺔ ﺍﻟﺼﺤﻴﺔ ‪ ......................... :‬ﺃﻳﺔ ﻋﻼﻣﺎﺕ ﻓﺎﺭﻗﺔ ‪............................................ :‬‬
‫ﺃﺧﺮﻯ ‪ .................‬ﻋﺪﺩ ﺍﻷﺑﻨﺎء‬ ‫ﻣﺘﺰﻭﺝ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ ‪ :‬ﺃﻋﺰﺏ‬
‫ﺍﺳﻢ ﺍﻟﺰﻭﺝ ‪ /‬ﺍﻟﺰﻭﺟﺔ ‪........................................................................................ :‬‬
‫ﻣﻜﺎﻥ ﺍﻻﻗﺎﻣﺔ ( ﺍﻟﺪﺍﺋﻢ ) ‪...................................................................................... :‬‬
‫( ﺍﻟﺤﺎﻟﻲ ) ‪.................................................................................... :‬‬
‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﺒﺮﻳﺪﻱ ‪.............................................................................................. :‬‬
‫‪.....................................................................................................................‬‬
‫ﺍﻟﺒﺮﻳﺪ ﺍﻹﻟﻜﺘﺮﻭﻧﻲ‪................................................................................................‬‬
‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ ‪.................................................................................................... :‬‬

‫ﺍﻟﻤﺆﻫﻼﺕ ﺍﻟﻌﻠﻤﻴﺔ‬
‫ﺍﻟﺪﺭﺟﺎﺕ‬
‫ﺍﻟﺠﺎﻣﻌﺔ‬ ‫ﺍﻟﻜﻠﻴﺔ ‪/‬‬ ‫ﺳﻨﺔ‬ ‫ﺍﻟﻤﻌﺪﻝ ﻋﺪﺩ‬ ‫ﺍﻟﻌﻠﻤﻴﺔ‬
‫ﻭﻣﻜﺎﻧﻬﺎ‬ ‫ﺍﻟﻤﻌﻬﺪ‬ ‫ﻭﺍﻟﺘﻘﺪﻳﺮ ﺳﻨﻮﺍﺕ ﺍﻟﺘﺨﺮﺝ‬
‫ﺍﻟﺘﺨﺼﺺ‬
‫ﺍﻟﺪﻗﻴﻖ‬ ‫ﺍﻟﺪﺭﺍﺳﺔ‬
‫ﺍﻟﺜﺎﻧﻮﻳﺔ ﺍﻟﻌﺎﻣﺔ ﺃﻭ ﻣﺎ‬
‫ﻳﻌﺎﺩﻟﻬﺎ‬
‫ﺍﻟﺒﻜﺎﻟﻮﺭﻳﻮﺱ‬
‫ﺍﻟﻤﺎﺟﺴﺘﻴﺮ‬
‫ﺍﻟﺪﻛﺘﻮﺭﺍﻩ‬

‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﻜﺎﻣﻞ ﻟﺮﺳﺎﻟﺔ ﺍﻟﻤﺎﺟﺴﺘﻴﺮ ( ﻭ ﺍﺳﻢ ﺍﻟﻤﺸﺮﻑ ) ‪................................................... :‬‬

‫‪......................................................................................................................‬‬
‫‪................................................................................... ...................................‬‬
‫‪......................................................................................................................‬‬
‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﻜﺎﻣﻞ ﻟﺮﺳﺎﻟﺔ ﺍﻟﺪﻛﺘﻮﺭﺍﻩ ( ﻭ ﺍﺳﻢ ﺍﻟﻤﺸﺮﻑ ) ‪.................................................. :‬‬
‫‪......................................................................................................................‬‬
‫‪......................................................................................................................‬‬
‫‪.................. ....................................................................................................‬‬
‫ﺍﻟﺪﻭﺭﺍﺕ ﺍﻟﻌﻠﻤﻴﺔ ﻭﺍﻟﺘﺪﺭﻳﺒﻴﺔ‬

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 ‫ﻣﻮﺿﻮﻉ‬
‫ﻣﺪﺗﻬﺎ‬ ‫ﺍﻟﺒﻠﺪ‬ ‫ﺟﻬﺔ‬ ‫ﺍﻟﺪﻭﺭﺓ‬
‫ﻋﻘﺪﻫ‬
‫ﺎ‬
‫ﺍﻟﻰ‬ ‫ﻣ‬
‫ﻦ‬

‫ﺍﻟﺨﺒﺮﺍﺕ ﺍﻟﻌﻤﻠﻴﺔ ﻭﺍﻟﺘﺪﺭﻳﺴﻴﺔ‬

‫( ﺑﻌﺪ ﺁﺧﺮ ﻣﺆﻫﻞ ﻋﻠﻤﻲ )‬
‫ﺍﻟﻤﺴﻤﻰ ﺍﻟﻮﻅﻴﻔﻲ‬
‫ﺍﻟﻤﺪﺓ ﺍﻟﺰﻣﻨﻴﺔ‬ ‫ﻣﻜﺎﻥ ﺍﻟﻌﻤﻞ ﻭﻋﻨﻮﺍﻧﻪ‬
‫ﺍﻟﻰ‬ ‫ﻣﻦ‬

‫ﺍﺳﻤﺎء ﺍﻟﺠﻤﻌﻴﺎﺕ ﺍﻟﻌﻠﻤﻴﺔ ﺍﻟﻤﺸﺘﺮﻙ ﺑﻬﺎ‬

‫ﺍﺳﻢ‬
‫ﺍﻟﺠﻤﻌﻴﺔ‬
‫ﺍﻟﻌﻨﻮﺍﻥ‬
 ‫ﺍﻟﻠﻐـــــــــﺎﺕ‬

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 ‫ﻣﺤﺎﺩﺛﺔ‬ ‫ﻛﺘﺎﺑﺔ‬ ‫ﻗﺮﺍءﺓ‬ ‫ﺍﻟﻠﻐﺔ‬
‫ﻣﻘﺒﻮﻝ‬ ‫ﺟﻴﺪ‬ ‫ﻣﻤﺘﺎﺯ‬ ‫ﻣﻘﺒﻮﻝ‬ ‫ﺟﻴﺪ‬ ‫ﻣﻤﺘﺎﺯ‬ ‫ﻣﻘﺒﻮﻝ‬ ‫ﺟﻴﺪ‬ ‫ﻣﻤﺘﺎﺯ‬

‫ﺍﺳﻤﺎء ﻭﻋﻨﺎﻭﻳﻦ ﺛﻼﺛﺔ ﻣﻌﺮﻓﻴﻦ ﻣﻤﻦ ﻟﻬﻢ ﺍﻁﻼﻉ ﻋﻠﻰ ﻧﺸﺎﻁﺎﺗﻚ ﺍﻟﻌﻠﻤﻴﺔ‬
‫ﻭﺍﻟﺘﻌﻠﻴﻤﻴﺔ‬

‫ﺍﻻﺳﻢ‬
‫ﺍﻟﻌﻨﻮﺍﻥ‬

‫ﺍﻟﺠﻬﺔ ﺍﻟﻤﻠﺘﺰﻡ ﻟﺪﻳﻬﺎ ‪ ..............................‬ﻣﺪﺓ ﺍﻻﻟﺘﺰﺍﻡ ‪........‬‬ ‫ﻏﻴﺮ ﻣﻠﺘﺰﻡ‬ ‫ﻣﻠﺘﺰﻡ‬

‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎء ﺧﺪﻣﺔ ﺍﻟﻌﻠﻢ ‪.......................................................................................‬‬

‫ﺃﻳﺔ ﻣﻼﺣﻈﺎﺕ ﺃﺧﺮﻯ ‪:‬‬

‫‪......................................................................................................................‬‬
‫‪......................................................................................................................‬‬
‫‪......................................................................................................................‬‬

‫ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺪﺭﺟﺔ ﻓﻲ ﻫﺬﺍ ﺍﻟﻄﻠﺐ ﺻﺤﻴﺤﺔ ﻭﺃﺗﺤﻤﻞ ﻣﺴﺆﻭﻟﻴﺔ ﻋﺪﻡ ﻣﻄﺎﺑﻘﺘﻬﺎ ﻟﻠﻮﺍﻗﻊ‪.‬‬

‫‪//‬‬ ‫ﺗﺎﺭﻳﺦ ﺗﻘﺪﻳﻢ ﺍﻟﻄﻠﺐ‬

‫ﺍﻟﺘﻮﻗﻴﻊ ‪.................................‬‬
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